These phrases are about what we aspire to, what we value. They don’t describe a policy for getting there.

Many articles that use the term single payer to mean a goal often point out that other countries that guarantee coverage and care to their residents have gone about it in different ways.

Jonathan Oberlander summarizes these differences in this New England Journal of Medicinearticle:

U.S. observers often mistakenly lump all foreign health systems together under the single-payer label — a classification that grossly oversimplifies the range of models in place elsewhere. In some rich democracies (Germany, the Netherlands, and Switzerland among them) people enroll in multiple insurance plans, which are typically highly regulated and are operated by private companies or nonprofit associations…Most U.S. single-payer advocates instead have in mind emulating Canada, where all legal residents in each province or territory receive coverage from one government insurance plan for medically necessary hospital and physician services.

A Specific Policy

To others, single payer is a term that means more than the goal of access to good, affordable coverage and care. Instead, it is a literal description of how that coverage should be structured:

Physicians for a National Health Program (PNHP): Single-payer national health insurance, also known as “Medicare for all,” is a system in which a single public or quasi-public agency organizes health care financing…The program would…(replace) today’s inefficient, profit-oriented, multiple insurance payers with a single streamlined, nonprofit, public payer…

As noted in this quote, there is also a movement toward using the terms “single payer” and “Medicare for all” interchangeably.

To these groups, the focus on a “single government payer” is crucial. They are very specific in saying that employers would no longer be responsible for health care costs and coverage decisions. And they believe this structure is necessary both to reduce administrative costs and enhance negotiating power. They don’t believe that other hybrid approaches, such as those Oberlander mentions, above, should be considered.

Messaging

To make it even more confusing, messaging strategy also plays into what terminology is used.

Because “single payer” may not be very meaningful to people outside of the rarified world of progressive health policy, “Medicare for all” seems to be gaining more traction. By using the name of a familiar and popular program, Medicare, single payer supporters believe they can make the concept more approachable to more people.

Are they right? This poll shows that Medicare for all is the preferred terminology. In contrast, the June Kaiser Health Tracking poll finds little difference between the “Medicare for all” or “single payer” labels.

Whether one or more of the five terms listed under Goal in the first part of this blog would be any more popular is hard to say. Herndon Alliance, a group formed in 2005 to work on messaging prior to the run up to the fight to pass what became known as the Affordable Care Act (ACA), conducted extensive market research on how to talk about health reform. At the time, “quality, affordable health care” polled better than universal coverage. Without current messaging research, it’s hard to know what is the “right” terminology to use now.

So, What DO We Mean by Single Payer?

For the purpose of this blog series, I am choosing to refer to single payer as a goal, rather than a specific policy prescription.

While we may not agree on terminology, or on policy solutions, at least most of us can agree on the goal: quality, affordable coverage and care for all, universal health care, guaranteed lifetime coverage for all or whatever you choose to call it. And that is a good place to start the next phase of the discussion: how to get there.

Single Payer Is Not a Principle: Article in Democracy by Harold Pollack
(See especially the discussion under this heading: 2. Single payer provides one path to universal coverage. There are many others.)

Our mission is to serve as a catalyst that engages residents and communities in shaping a democratic health system that provides universal access to quality, affordable health care and promotes health in Connecticut. We believe that health care is a fundamental right and that our work is part of a broader movement for social and economic justice.

The events in Charlottesville, Virginia this past weekend threaten social and economic justice to its very core. Just in July, the Ku Klux Klan demonstrated on the New Haven Green. As the title of Sinclair Lewis’ book, It Can’t Happen Here suggests, it can happen here too!

Throwback to Another Time

I was a kid in 1968 when race riots broke out nationwide, and when I first read The Diary of Anne Frank. After almost 40 years working on social justice issues, on Saturday I felt the same pang in the pit of my stomach that I felt at the age of 10. Fear and profound sadness. Except that I also felt completely pissed off. It feels like we make no progress and I live in dread for my multi-racial, multi-ethnic, multi-lingual family, friends and community.

The Browning of America

I thought about my cousin and her two adult children, who live in Virginia. They moved there from Puerto Rico a few years ago. Like Guam, Puerto Rico is a colony of the U.S. and we Puerto Ricans have been citizens for a century. But my cousin’s highly educated kids speak English with an accent and she doesn’t speak English well at all. They too are the targets of extremists. It doesn’t matter whether you have legal immigration status or not. What matters to these people is that America has “browned” and they don’t want their daughters and sons having brown babies, as recent comments by the Governor of Maine implied.

The news cycle of the past 48 hours has dwelled on how the white supremacists were armed, and in fact, out-armed the Charlottesville police. It was hard to distinguish police from “protesters.” The Virginia Governor defends his policing by saying that “except for the car terrorist incident” local and state police handled the armed “protesters” and not one shot was fired. What if the organizers had been black and brown?

Look Inside to Move Forward

The United States continues to live its dilemma. On the one hand, we hold the value of fairness very dear and have a strong charitable impulse, but we also have a deep streak of selfishness and righteousness. I believe this is rooted in the Calvinist tradition that poverty or sickness is the result of some moral failing and lack of personal responsibility. Even people originally from other countries often adopt this attitude. And the President is building his legacy on it. We all need to look inside ourselves for how much of that white Anglo-Saxon American identity we own. And we need to name it if we are to change.

The Foundation remains committed to doing better ourselves, as individuals and as an organization. We remain committed to working on racial justice and equity with diverse partners. In our work through the Protect Our Care Connecticut campaign we seek to connect a broad cross-section of people in our state to one another, united around the common goal of health care for everyone, regardless of color, creed, gender identity, political persuasion or zip-code.

The high cost of prescription drugs in the United States is unsustainable. Spending on prescription drugs is growing faster than other health care expenses. A growing number of Americans report they are struggling to afford their medications.

States can play a key role in protecting everyday people from unfair and unaffordable prescription drug prices.

Connecticut is one state that has stepped up. We passed an important piece of prescription drug legislation with bi-partisan support, SB 445. And Connecticut’s Health Care Cabinet is focusing its work this year on the issue of high drug costs, both through its regular meetings and through four newly established work groups.

The new report analyzes promising state-level approaches to addressing high and skyrocketing prescription drug prices, providing recommendations to guide policymakers and advocates. It offers a valuable roadmap for Connecticut and other states that are ready to take on the challenge of unaffordable prescription drugs.

Like this:

Last week, for the first time in quite a while, Congress was not trying to repeal and replace the Affordable Care Act.

With the immediate emergency of Congressional repeal on (temporary?) hold, we thought it might be a good opportunity to share four recently published think pieces on why/how TrumpCare was stopped.

The first two links are to blog posts that focus on the machinations in Congress and the White House. The second two focus on the huge role played by grassroots activists. One of these articles was written after the dramatic vote in the Senate that stopped repeal (at least for now) and the other was written one week earlier.

Like this:

Getting to universal health care in the U.S. is a political challenge. The two big obstacles are:

Individuals fearing change, worrying that they could end up worse off

Health industry vested interests knowing they will be worse off

The first blog in this series addressed the fear of change by individuals that can be ignited when wholesale alteration of their health coverage starts to become a real possibility.

This blog focuses on industry fears, and their investment in maintaining the status quo.

There is a huge amount of money in the US health care system. As we heard over and over again in the recent fight to stop repeal of the Affordable Care Act (ACA), it is one sixth of the US economy.

We spend an average of twice as much per-person on health care as any other wealthy nation. Pharmaceutical corporations and many hospital companies and systems are making a lot of money off of that system. Health insurance company profits are booming, too.

As dysfunctional as our current health care system is, changing to a government-funded, highly regulated health care system is not seen as a positive goal, instead it poses a clear threat to industry players.

The Threat of Losing Negotiating Power to Set Prices

While many single payer supporters focus on its ability to eliminate a huge amount of administrative expenses, the more hidden reason single payer is expected to save money is that the system will have the negotiating power to pay lower prices for care.

The top reason that the US health care system is so expensive is high and rising prices. Monopoly pricing is the name of the game for pharmaceutical corporations, for brand name drugs and, increasingly, for generics, too. Right now Big Pharma is largely able to charge what the market will bear, even in the Medicare program.

Hospital systems are learning that forming monopolies is good business. They are buying up physician practices and taking over competitor hospitals. Research shows that hospital consolidation leads to higher prices, by strengthening hospitals’ negotiating power.

A fragmented insurance industry has generally passed along huge hospital and pharmaceutical price increases to their customers, after taking their cut.

All three of these industries and their shareholders, as well as many other companies in health-related businesses, are not going to walk away quietly when the health care for all fight picks up steam.

Lobbying

High prices fund profits, but they also fund lobbying capability. Pharmaceutical corporations spend more money on federal government lobbying than any other industry. The insurance industry is right behind them.

Since Medicare expanded to cover prescriptions pharmaceutical corporations have successfully fought any effort to require them to negotiate prices. If the recent single payer fights in Colorado and California are any indication, the health care industry will be ready and willing to expend significant dollars to stop single payer legislation.

High Prices

The fact that health care prices are already so high in the US poses a major threat in itself to a successful transition to single payer. As Joshua Holland’s article published this week in The Nation explains:

(Other countries) established their systems when they weren’t spending a lot on health care, and then kept prices down through aggressive cost-controls.“Bringing costs down is a lot harder than starting low and keeping them from getting high,” says (Dean) Baker.

Eliminating Administrative Costs = Eliminating Jobs

And finally, there is the jobs issue. As health industry players are only too ready to point out, we also can’t forget that cost savings for the health care system will translate into job losses.

A more streamlined system with much greater power over costs will certainly impact employment not only in the insurance industry, but in hospital and physician billing departments, insurance brokers and many other more hidden parts of our complex system. As Charles Gaba points out:

Well over half a million people work directly for health insurance companies, plus a couple million people in directly related industries…Now, I know what you’re saying, “Cry me a river! Different industries are changing and becoming obsolete all the time! You don’t see anyone shoring up the abacus or slide rule industry these days, do you?”… True, and I’m not saying making such a sweeping change shouldn’t be done … I’m simply pointing out some of the reasons why it’s extremely difficult to do so.

It’s Political AND It’s Personal

The jobs issue brings us full circle back to individuals’ fear of change, as discussed in the first blog. Health care is personal for all of us, even if we don’t work in health care. As Gaba reminds us,

Remember, changing healthcare policy isn’t only about what looks logical on paper, it’s about persuading people (either voters, politicians, or both) to agree with you. The emotional aspect is a tough nut to crack, especially when it changes from the hypothetical to the here and now.

That’s not to say we shouldn’t fight for universal health care – of course we should. But that IS to say that HOW we get there is going to be very important.

Jim Wadleigh, the CEO of AHCT, opened with the statement that was later released to the press. He mentioned 2 major threats to the state’s exchange – which have been persistent throughout the year:

1) The many (so far unsuccessful) attempts to repeal the Affordable Care Act, and

2) The potential for both exchange insurers (Anthem and ConnectiCare) to leave Access Health CT without any insurers.

A third threat was the dominating topic of discussion: whether or not the federal government will pay cost sharing reduction (CSR) payments to insurers. CSR’s help to lower costs for very low-income people on the exchange.

If the CSR’s aren’t going to be paid in 2018:

It could cause one or both insurers to leave the exchange

Insurers would need to resubmit rate requests taking into account CSR’s which would likely lead to even higher premiums.

While some solutions were discussed, the Board did not land on any solid plans for dealing with these challenges, as federal level uncertainty is trickling down to the state. At the June AHCT Board meeting, there was some discussion of what might happen in the event of two, one and no insurers on the exchange: see page 19 of the June presentation.

There are some critical dates coming up that will hopefully lead to a clearer path forward in 2018:

Thank you to EVERYONE who answered our call to send selfies and/or photos of loved ones. We gathered even more photos to illustrate that millions of people will be hurt if the Senate votes to decimate our health care.

We also want to thank everyone who showed up, cheered, chanted and stood together against those who would roll back important health care gains in this country.